MEDICARE: DEVON CRAFT DO PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871052175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEVON CRAFT DO PC

Provider Business Mailing Address
First Line	:	38 N MAIN ST
Second Line	:
City	:	ELLENVILLE
State	:	NY
Zip	:	12428-1017
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	38 N MAIN ST
Second Line	:
City	:	ELLENVILLE
State	:	NY
Zip	:	12428-1017
Country	:	US
Telephone Number	:	845-647-5430
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DEVON CRAFT
Credential	:	DO
Telephone Number	:	845-901-1072

Provider Enumeration Date	:	03/16/2019
Last Update Date	:	03/16/2019

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